Cranford Hospice – Dying in Hawke’s Bay, Part 1

What follows is Part 1 of a lengthy two-part article on Cranford Hospice, Dying in Hawke’s Bay. Tomorrow we will post Part 2. [For the impatient, the entire article can be downloaded here.]

Dying in Hawke’s Bay is one of the most in-depth articles BayBuzz has published. Writer/reporter Mark Sweet and I spent at least sixty hours pulling it together. We interviewed seventeen knowledgeable insiders in depth, some repeatedly, and an equal number informally. And we reviewed a range of documents and web resources … many of which you can find in the Issues section of the BayBuzz website.

Why?

Because perhaps there’s no more iconic and beloved public service institution in Hawke’s Bay than Cranford Hospice. One that has touched thousands of families over the years, and with a blossoming senior citizen population, will touch even more to come. An institution that receives 30% of its annual funding from the generous donations of the community. An institution that’s broken.

Since November we’ve received numerous requests – pleas, in some cases – to look into what was described as a seriously dispirited facility. Dysfunctional to the point that caregiving might be compromised.

Dying in Hawke’s Bay – Part 1
By Mark Sweet & Tom Belford

Not a pleasant topic.

But an inevitable one.

And one of special policy importance in Hawke’s Bay, where people over age 65 represent the fastest growing segment of our population. For those afflicted with terminal illnesses like cancer, which often bring unrelenting pain, the final path to death can be especially dire. Special care – palliative care – must be provided to these individuals to ease their suffering (and that of their families) and enable a dignified passing.

In Hawke’s Bay, that has been the mission of Cranford Hospice for more than twenty-five years. During that period, our community has developed both tremendous pride and trust in the care provided by Cranford. But now that trust has been shaken by a very public dispute between present management, as provided by Presbyterian Support, and former and present clinical staff, who allege that quality of care has suffered in an environment of insensitivity and mis-placed responsibility at best – and bullying and intimidation at worst.

A range of charges have been brought to BayBuzz, and we have investigated them through a series of in-depth interviews with knowledgeable parties, as well as reviewing pertinent documents made available to us. Certain parties at the centre of the controversy spoke only superficially with us – notably, Barry Keane, Executive Director of Cranford Hospice; Shaun Robinson, CEO of Presbyterian Support; and Ron Hall, Board Chair, Presbyterian Support.

Our conclusion … Cranford Hospice is broken in spirit, and quite possibly the quality of care provision is diminished as well. Intervention by a responsible body – Hawke’s Bay District Health Board (HBDHB) – is clearly required if issues are to be fully explored, disputes resolved, and public confidence restored. Here is our story. Supporting documents, some not previously published, can be found on the BayBuzz website, enabling readers to draw your own conclusions.

Palliative Care
To understand the current dispute, a bit if history is required.

In February 2001 then Minister of Health, Annette King, announced the New Zealand Palliative Care Strategy.

Palliative care was succinctly defined as “the care of people who are dying from active, progressive diseases or other conditions that are not responsive to curative treatment.” The document emphasised that palliative care “embraces the physical, social, emotional and spiritual elements of well-being … and enhances a person’s quality of life while they are dying. Palliative care also supports the bereaved family/whanau.”

The Strategy contained nine steps to implement the vision of providing “timely access to quality palliative care services” to all people who are dying. District Health Boards were given responsibility and funding for implementing the strategy.

In Hawke’s Bay Cranford Hospice had been providing this service already for 20 years and was regarded as a model of palliative care in the community. They were the obvious vehicle to assist the Government’s policy, and the HBDHB contracted Cranford to do the job.

Up until this time Presbyterian Services had taken a hands off management attitude towards Cranford, and from it’s beginning in 1982 the Hospice developed its own culture of caring for the dying.

Jack Mackie was the Director when Presbyterian Social Services Association bought Cranford Hospital from the Royston Trust Board. “Cranford was allowed to develop on its own,” he told Baybuzz, “The PSSA were not involved.”

John and his wife Margaret were especially interested in the work of Dame Cicely Saunders at St. Christophers Hospice in London, and her four goals were used as a guide in the development of Cranford:

1. To care humanely for the terminally ill.
2. To provide not merely for the patient’s medical requirements, but also for the spiritual and emotional needs of the patient and loved ones.
3. To give family and friends the opportunity to share actively in the care, comfort and support of the dying individual.
4. To make the patient’s final days as painless, happy and meaningful as possible.

From the beginning, the aspirations of Cranford were the same as those which came later in the New Zealand Palliative Care Strategy of 2001.

From the outset, Cranford was a community asset. The first volunteers came from women’s groups associated with the churches and from the Country Women’s Institute. Fundraising and donations were the sole source of income, and Jack Mackie ensured that PSS, “did not proclaim involvement.”

With the appointment of Dr Libby Smales as Medical Director in1985, Cranford’s success was assured. She had trained at St. Christopher’s and as Jack Mackie observed, “Libby understood the spiritual aspect of dying, and the importance of family involvement. She created a flat management structure with relationships of equality where communication was easy and everyone was involved in patient care.”

Under the direction of Dr Smales, Cranford matured into a model of best practice in palliative care. Numerous professional articles written by EA Smales, HG Sanders, KL Lum, and AP Denton testify to the reputation of the team.

Libby Smales left Cranford in 2000. Her successor, Kerryn Lum, had been with the hospice since 1996.

A change in Presbyterian Support management also occurred in 2002 with the appointment of Shaun Robinson as CEO. This marked a change in the relationship between PSEC and Cranford which saw PSEC assume more and more control over Cranford affairs until arriving at the situation we have today, where Cranford staff are directly answerable to the CEO of PSEC. When Baybuzz contacted Cranford Director, Barry Keane, he said he couldn’t talk to us without the permission of Shaun Robinson. A far cry from Jack Mackie’s hands off approach.

In August 2007 a Review of Management and Leadership Functions and Structure (Harper/Devine) recommended that: “PSEC recognises the dynamic tension between Cranford and the rest of PSEC, valuing the individuality and uniqueness of the strong Cranford brand and what it offers PSEC while encouraging the development of collaborative innovative organisational wide synergies.”

To PSEC this was an invitation to restructure Cranford, and within a year the three top positions were filled by new appointments from outside Hawke’s Bay, old relationships were severed, with many people feeling very badly treated.

The Complaints
”We do not intend to participate in any further debate via the media. We believe that most reasonable people would agree with our decision” is how the PSEC Board concluded an “open letter to assure the public, staff and supporters that they can have total confidence in Cranford Hospice.” (HB Today advert, November 2009)

The letter was in response to “articles and correspondence in the media … based on the opinions of a small number of people.”

Doctors Smales and Lum were obviously among the “small number” of people who had “unjustified criticisms,” because two weeks before the PSEC letter they issued a joint statement in which they referred to “a climate of bullying and intimidation” at Cranford. They spoke of the “much admired interdisciplinary team being systematically deconstructed,” and how “Many benefactors are now cautious of their ongoing support.”

When things went sour at Cranford, Libby Smales was an obvious conduit for people’s concerns and grievances. After a year of being constantly asked, “to do something about the destruction of Cranford,” she approached the PSEC Board in September 2008, but her request to, “take with me a number of professional people who had been or were involved with the Hospice,” was declined by Chairman Ron Hall. Also declined was her request that her presentation be, “to the Board alone, as many of the concerns relate to Hospice management …”

What Dr Smales did present to the PSEC Board was a clear and illustrated picture of dysfunction at Cranford:

• The Inter-Disciplinary Team approach, which fostered co-operation and easy communication was being replaced by an outdated, hierarchical, hospital model, unsuitable to achieving Current Best Practice in Palliative Care.
• Experienced staff were struggling to get what patients need/deserve from inexperienced staff, who were unsure, hesitant, and acting in isolation because of the destruction of the team.
• The cohesive, mutually supportive way of working with GP’s, who previously could discuss problems with any of the Inter-Disciplinary Team (in house team, Palliative Care Co-ordinator, pharmacist, on call doctor) was lost.

Supporting Dr Smale’s concerns were letters from people involved with Cranford.

From a Napier GP: “I don’t know what to tell patients about the hospice service any more, as I don’t want to raise their expectations … Recently when I rang Cranford to obtain a Special Authority for a mutual patient, I was stunned to hear that there would be no pharmacist available until the next day. Yes I can get a Special Authority myself, but it can take up to two weeks to get a reply … Cranford pharmacists had an excellent system for immediate responses. Palliative Care patients don’t always have two weeks to wait.”

From Medical Staff: “Redundancies and resignations … include hospice manager, principal nurse, medical director, councillor, massage therapist, and two pharmacists. Several staff members have taken stress leave. Many others are expressing levels of stress, distress, and low morale.”

From Senior Nurses: “New medical personnel are inexperienced and and hesitant resulting in poor symptom control. This is often resulting in painful and distressing deaths … the loss (of the Pharmacy team) is putting a huge strain on the team.”

From Dr Kerryn Lum: “Loss of teamwork, insufficient staffing, and loss of trust and goodwill has meant that the excellent pro-active anticipatory care planning for which Cranford was renowned is reduced to reactive crisis, with a slower response time than ever before. Dying patients and distraught families do not have time to wait.”

Presbyterian Support’s response was to commission a review of Cranford by Dr Sandy McLeod, a Palliative Care Physician from Christchurch. Dr McLeod’s report has not been released by PSEC (it should be), but what is known is that when he asked staff which regime would they rather be under if they were dying – the old or the new – the majority chose the old.

There is no doubt that the restructuring of Cranford has compromised the quality of care, and there is little indication that concerns expressed in September 2008 (and since) have been resolved.

End, Part 1.

Part 2 will examine Cranford management, DHB’s position, and recommend a path to resolution.